Talk to Cardiac Surgeon on Seeking Advice On Alternatives To Bypass Surgery
Asking For Mother, Female 68, Hassan Abdal
Dear Doctors,
My mother, aged 68, has been diagnosed with Coronary Artery Disease. We consulted doctors at RIC and AFIC, who recommended a bypass surgery. However, our family, and particularly my mother, is very apprehensive about this procedure. She has expressed a strong preference to rely solely on medications, stating that she is willing to accept the risks associated with this approach.
*Left Main Stem:* Distal tempering with critical disease Bifurcating
*Left Anterior Descending Artery:* Moderate ostial critical disease in proximal to mid course (calcific vessel)
*Left Circumflex Artery:* Non Dominant in proximal course critical ostioproximal disease in OM branch
*Left Corony Artery:* Dominant critical disease in proximally calcific vessel
*Her medical profile includes the following:*
She is diabetic, with an average blood sugar level of 350.
She has been advised that her kidney condition is not good.
She is also overweight, which further complicates her condition.
Gi
Dr. Mahrukh Zahoor - Cardiac Surgeon
MBBS, MCPS (Gen Surgery), FCPS (Cardiac Surgery) | Islamabad
Call. 042-32591427, add 92 or 0 before mobile number. Needs discussion
I apologize in advance for my words. "Your mother disease is curable if she goes for surgery otherwise it is kind of a suicide with knowing that there is complete cure of the disease and still waiting for the worse".Left main disease should be treated at the earliest , in the same admission where the angiography was done.
She needs bypass surgery
Dr. Muhammad Yasir - Cardiac Surgeon
MBBS, FCPS* (General Surgery), Diploma in MIS (Germany), MD (USA), Member American College of Cardology, Member European Society of Cardiology, Member of CCFP | Lahore
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Thank you for sharing these details. It’s understandable that your mother feels apprehensive about undergoing bypass surgery, especially given her age and other health conditions. However, considering the severity of her coronary artery disease (CAD) and the critical involvement of the left main coronary artery and other major branches, this is a high-risk situation. Here’s a breakdown of key points to consider:
Risk Analysis of Current Condition
1. Left Main Coronary Artery Disease: This is critical as it supplies a significant portion of the heart. Disease in this artery greatly increases the risk of heart attack and sudden cardiac events.
2. Multivessel Involvement: Severe calcification and critical disease in multiple arteries indicate extensive atherosclerosis.
3. Diabetes: Her uncontrolled diabetes (average blood sugar level of 350) accelerates vascular damage and increases surgical and non-surgical risks.
4. Kidney Function: Impaired kidneys (likely chronic kidney disease) further elevate surgical risks but also limit the effectiveness of certain medications.
Surgery vs. Medical Management
• Bypass Surgery (CABG):
• Most effective in revascularizing critical areas and preventing major cardiac events in patients with extensive CAD, especially in diabetics.
• While it carries surgical risks, modern techniques and careful perioperative management can mitigate these.
• A surgery-first approach is often recommended for left main disease and multivessel disease in diabetics.
• Medications Alone:
• Could be an option for patients who are absolutely unfit for surgery or unwilling to undergo it.
• However, it does not reverse or significantly stabilize the progression of severe blockages, especially in left main disease.
• It may not provide sufficient protection against heart attacks in such high-risk cases.
Important Considerations for Surgery:
1. Multidisciplinary Approach: If surgery is considered, her team should include cardiologists, cardiac surgeons, nephrologists, and anesthesiologists to optimize outcomes.
2. Pre-Surgical Optimization:
• Strict blood sugar control is essential. Insulin therapy may be required to reduce glucose levels rapidly.
• Weight management and dietary interventions should begin immediately.
• Renal support, including nephrology consultation, to minimize kidney stress before and after surgery.
If Opting for Medication Only:
• She would need aggressive medical therapy, including:
• Dual antiplatelets (aspirin + clopidogrel or ticagrelor).
• High-dose statins (atorvastatin or rosuvastatin) to lower cholesterol.
• Beta-blockers and ACE inhibitors/ARBs, if tolerated, to manage heart function and blood pressure.
• Regular monitoring for worsening symptoms like chest pain, breathlessness, or fatigue.
• Lifestyle adjustments, such as a strict diabetic diet, weight control, and regular low-intensity activity (if approved), are crucial.
Family and Emotional Support:
Given her apprehension, it’s important to:
1. Arrange a second opinion, preferably from a high-risk cardiac surgery team.
2. Have a detailed discussion about the risks and benefits of both surgery and medical management.
3. Consider involving a psychologist or counselor to address her fears about the procedure.
Ultimately, the decision should be made collaboratively, with a focus on her quality of life and personal wishes, balanced against the medical urgency of her condition.
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